Question

A patient, Jim Jones, has come in complaining of bilateral ear pain, runny nose, and shortness of breath. His temperature is 101.8 F temporal, blood pressure 110/80 mm/Hg, pulse 86 bpm, respirations at 22 rpm. The doctor checks his ears and finds the patient has bilateral otitis media and bronchitis and treats the patient with Levaquin 500 mg one daily for five days. He is to return if his symptoms do not improve. Make up a SOAP note in your discussion. Is there other information that would be helpful that you could include into a note? Be specific when answering.

Answer 1

Subjective: The patient is complaining of pain non both ears,runny nose and shortness of breath

(Past medical and surgical history ,allergies drug and food,detailed personal history should be included)

Objective:

• T:101°F
• P:86 bmp
• R:22rpm
• BP:110/80mm/Hg

(Physical examination :Swelling of the inner ear drum

Chest x Ray to rule out breathing difficulty due to any chest infection

Review with a ENT and pulmonologist)

Assessment:

Bilateral otitis media +

Bronchitis+

Plan:

• To stat with antibiotic Levaquin 500mg OD× 5days
• To provide antipyretic to reduce body temperature and analgesic to relieve pain
• Ear drops to relieve any wax or infectio directly into the ear
• Encourage the patient to lie on propped up position to encourage draining
• Follow up